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a handbook for junior doctors
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RMO Handbook To the RMO This handbook has been designed to act as a quick reference to assist you in your daily activities, particularly in relation to after hours and ward calls. It is not meant to be a medical compendium, and if you are ever unsure about anything always ask your registrar, the senior nurse, another resident, or the consultant. Additionally you will find detailed clinical information as well as policies and procedures available electronically via the QH website. It is recognised that the challenges of working in the early years post graduation are many. You are encouraged to access all available support and to seek guidance when necessary. Never defer asking for help due to fear of any criticism for doing so. This approach will contribute to high quality patient care as well as contribute to the enhancement of your own personal training and development. Acknowledgements This handbook has been adapted from a number of sources including the Ipswich Hospital Intern Survival Pocketbook written by Dr Ian Scott, the Princess Alexandra Hospital Handbook, and a number of other facility manuals. Version: 2.0 (Last updated October 2011) For feedback and corrections please Email: [email protected]
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TABLE OF CONTENTS Section A – Emergencies
When to call a MET ........................................................................... 3 Pathology: Specimen Collection Tube Recognition ......................... 5 Medical Emergency Flowcharts ........................................................ 6
Section B ‐ Looking After Yourself .............................................................. 11 Section C – Ward Work and Pre‐admissions
General Daily Ward Work ................................................................. 12 Pathology .......................................................................................... 18 Pharmacy – Prescribing .................................................................... 20 Infection Control ............................................................................... 23 Pre‐admission Clinics ....................................................................... 26
Section D – Ward Call
Do’s and Don’ts ................................................................................. 27 Ward Call........................................................................................... 27 Ringing the Registrar ........................................................................ 29 Clinical Handover .............................................................................. 29 Simultaneous Critical Calls ................................................................ 30 Phone orders..................................................................................... 30 SBAR Communication Tool ............................................................... 32
Information for Common Calls:
Reference for clinical problems ....................................................... 33
(CKN eBOOKS “On Call”, Marshall & Ruedy, Cadogan 1st ed) https://www‐mdconsult‐com.cknservices.dotsec.com/books/page.do?eid=4‐u1.0‐B978‐0‐7295‐3803‐9..X5001‐5&isbn=978‐0‐7295‐3803‐9&uniqId=287598495‐2#4‐u1.0‐B978‐0‐7295‐3803‐9..X5001‐5‐‐TOP
Anticoagulation..................................................................... 34 Cardiac Arrest........................................................................ 34 Chest Pain.............................................................................. 35 Drips and Peripheral IV Cannulation..................................... 35 Endocrinology ...................................................................... 35 Falls ...................................................................................... 36 Hypoglycaemia – see Endocrinology ................................... 35 Hyperglycaemia – see Endocrinology ................................... 35 Mental Health Basics ............................................................ 37
Section E ‐ Reporting and Medico‐Legal Requirements
Withholding and Withdrawing Life‐Sustaining Measures ................ 40 Informed Consent ............................................................................. 44 Certifying and Reporting Death ....................................................... 46 PRIME (Clinical Incident Management System)................................ 48
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When to call a Medical Emergency Team (MET) The MET provide an early and rapid response to seriously ill patients with life threatening conditions, or to patients who are at risk of a cardiopulmonary arrest. The goal is to identify and treat patients at risk of cardiac arrest, unplanned ICU admission or unexpected death.
A MET call can be initiated by any hospital staff member.
Dial < Insert local data> State “MET call” and “destination”
When to get help
Emergencies:
Consult a senior staff member about any patient requiring more than normal ward care.
Acuity of illness, aetiology, co‐morbidity, responsiveness to intervention, predicted duration of illness and interventional monitoring need determine individual priority for critical care management.
For more detailed information a good reference is: Anaesthetic Intensive Care 1995; 23: 183‐186 “The Medical Emergency Team”, A Lee et al
Call a MET for all cardiac and respiratory arrests and all conditions listed below:
Adult Criteria
ACUTE CHANGES IN: PHYSIOLOGY
AIRWAY Threatened
BREATHING All respiratory arrests Respiratory rate < 5 Respiratory rate > 36
CIRCULATION
All cardiac arrests Pulse rate < 40 Pulse rage > 140
Systolic Blood Pressure < 90mm HG
NEUROLOGY Sudden fall in level of consciousness
(fall in GCS of >= 2 points) Repeated or prolonged seizures
OTHER Any patient you are seriously worried
about that does not fit the above criteria
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Paediatric Criteria
ACUTE CHANGES IN: PHYSIOLOGY
AIRWAY Threatened
BREATHING
All respiratory arrests Severe respiratory distress Hypoxaemia: SpO2 <90% in any amount of oxygen; SpO2 <60% in any amount of oxygen (cyanotic heard disease) Cyanosis Apnoea Tachypnoea: Term‐3mths >60bpm 4‐12mth >50 1‐4years >40 5‐12years >30 12+ years >30
CIRCULATION
All cardiac arrests Bradycardia/Tachycardia: Term‐3mths <100 bpm, >180bpm 4‐12mth <100bpm, >180bpm 1‐4years <90bpm, >160bpm 5‐12years <80bpm, >140bpm 12+ years <60bpm, >130bpm Systolic Blood Pressure Term‐3mths <50mmHg 4‐12mth <60mmHg 1‐4years <70mmHg 5‐12years <80mmHg 12+ years <90mmHg
NEUROLOGY Sudden fall in level of consciousness
(fall in GCS of > 2 points) Repeated or prolonged seizures
OTHER Any patient you are seriously worried
about that does not fit the above criteria
Paediatric Crit Care Med 2009 Vol. 10, No. 3 p308
To call a MET: <insert local data>
State “MET CALL” and the location of the patient
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Medical Emergency Flowcharts
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Looking After Yourself
The intern year is a demanding transition from student to professional. Many people commencing work in a clinical setting find the environment and responsibilities bewildering and exhausting, and experience a type of ‘culture shock’. Some interns react with frustration, anger and resentment to the organization; others feel unhappy or lose their confidence and begin to doubt their abilities. The work you will be doing may at times be distressing. Looking after critically unwell and dying patients can be very challenging. You may sometimes feel unsupported, especially in the setting of shift work, sleep deprivation and a heavy workload. Allow several months to familiarize and socialize yourself into the new work environment, and accept there will be disappointments when you confront your knowledge gaps and recognize your performance weaknesses – don’t be too tough on yourself. Ask for help from your colleagues and know that there is plenty of support for your difficult new role. It can be easy to give a low priority to food, sleep, friendships, breaks from work; some people don’t even stop at work to drink water or go to the toilet. Your personal health is vital to your success as a doctor and your happiness. Carry snacks and try to stop every few hours for a break. Most of the staff you work with will respect these requirements. Very few things can’t be deferred for 15 minutes while you grab something to eat and drink. Having your own GP is important, both for your preventative health and in cases of acute illness. You will need medical certificates from time to time, and having your own doctor rather than having to present to your own emergency department is a good idea! Research shows 20 – 30% of interns experience depression. PLEASE seek help early. If you have a concern about a colleague, or if you feel you aren’t really coping, or you feel miserable and want to talk to some‐one, a number of options are available to you:
Talk to the DCT or MEOs (they are strong advocates for your well‐being)
Contact Doctors Health Advisory Service (DHAS) a confidential service supported by Royal Colleges and AMA, and staffed by experienced GPs supported by a panel of Consultants with expertise in dealing with medical conditions of colleagues.
DHAS is available 24 hours a day by phoning (07) 3833 4352.
Contact Queensland Health Employee Assistance Scheme (EAS) PH: 1300 361 008. They can assist you with information about confidential, free appointments with a private counselor.
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Section C ‐ WARD WORK and Pre‐admissions
Working in a Ward 1. GENERAL ISSUES
During the week before starting a new term, organise to meet with the outgoing intern and be briefed about ward routine regarding your new unit.
Each unit will have an orientation procedure; ensure you obtain a copy of the unit induction manual (preferably prior to commencement) and are provided with an adequate orientation to the unit.
On first arriving in your unit introduce yourself to the staff and familiarise yourself with times for ward rounds, unit and clinical meetings and, if relevant, operating sessions. Ensure you comprehensively understand the roles of Allied Health staff
Make an appointment to meet your Term Supervisor if this has not already been arranged for you.
Introduce yourself to the nurse in charge of your unit. He or she will want to speak with you and will provide you with a wealth of information and guidance about how you should organise your work within the day to day functioning of the unit.
Understand as soon as possible the functioning of the ward, its layout and equipment, particularly the resuscitation trolley and other emergency equipment. Ask your registrar to show you how to work any equipment as soon as possible. Do not assume you know.
Ask registrar/nursing staff about any particular requirements your consultants may have, eg lying and standing blood pressure, syphilis serology, etc.
Ensure you understand important administration processes (eg if required to take leave of absence; timesheet requirements)
2. ADMISSIONS
Introduce yourself to the patient (establish rapport), state your role in the health team, orientate the patient a little more to the ward/unit if required.
Take history and perform examination. You may need to speak to relatives or witnesses to confirm the history.
Write up findings in chart (black pen). Always sign, date, time and stamp or print your name beside your signature.
Be concise and as accurate as possible in documenting the patient’s clinical details.
Document differential diagnosis or problem list.
Look up any test results available.
Decide what other tests may be necessary; check consultant requirements or clinical pathway if available; liaise with registrar; resist the temptation to over‐order.
Take or arrange for blood to be taken if indicated.
Arrange or perform an ECG if indicated.
Organise further investigation and liaise with various departments/hospitals and registrars re: CT Scans, nuclear medicine, endoscopies, etc.
Anticipate and begin discharge planning from first day of admission ensuring you seek advice from relevant Allied Health professionals.
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Liaise with GP/ Nursing Home / Hospital etc. re past history, medications, drug allergies (including reactions to contrast dye/iodine), and past functional capacity.
Communicate to the patient/relatives the nature of the problem and the expected duration of the admission with sensitivity. Ensure you have the patient’s consent to discuss their condition with relatives and others.
Inquire as to patient’s previous level of independent functioning, social support, and psychosocial risk factors.
Decide about ongoing treatment, ie medications, fluids and write it up.
Ensure that the registrar knows about the admission. If the registrar is very busy or tired remember to remind them of the patient before you go off duty if they have not yet seen the patient.
Discuss case with registrar before instigation of treatment.
Anticipate baseline investigations morning of arrival ie Baseline blood tests, CXR, ECG – forms can be left on ward to be completed with patient on arrival.
3. ONGOING PATIENT CARE PATIENT MANAGEMENT
Each day upon arrival obtain a list of patients in your unit for that day and discuss with nursing staff any changes in patient conditions. Enquire about patients reviewed by after hours ward call due to significant clinical issues. Then prioritise tasks. (see Clinical Handover section)
Liaise with allied health staff.
Remember that "medical" patients get surgical problems and vice versa.
See and examine each patient at least once daily, maybe more if ill ‐ report changes to registrar, and write a note in chart.
Deal with any patient difficulties that arise, eg chest pain, SOB, urine output, headache.
Daily review of medications and fluids: Ensure medications which require variable daily dosing (eg warfarin, heparin, insulin) are written up for the next shift.
Explain to patient and relatives their progress and procedure results.
Review pathology and radiology results daily. Do not go home unless you have organised someone to chase up any outstanding results for the day.
Organise further investigations as needed. Do not re‐order simple blood tests (eg FBC, LFTs, Urea & Electrolytes/Creatinine) merely to monitor clinical condition if patient is clinically stable.
Collect blood as necessary for urgent tests.
Do ECG and IV resites as indicated.
Complete Nursing Home Forms, Hostel Forms, Interim Care.
Provide detail of patient’s condition to ward call resident – especially if it is considered necessary to review patient after hours. Quality effective handover is essential to ensure information is shared and ensures patient safety. (See Clinical Handover section)
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4. WARD ROUNDS
Prioritise and organise your time to deal with both pressing clinical problems and your attendance at rounds.
Come well prepared with the results of key investigations and any other important information about your patients – including detail provided during handover from after hours rostered staff. (Writing important results in chart ie key results which are being closely monitored or have undergone significant change is a good practice, but do not waste time entering all abnormal results if these are inconsequential to further management).
Have readily available the patients’ general clinical condition and other relevant details and be ready to present to the Consultant.
It is most important that statements made by the consultants concerning their patients during rounds be clearly recorded. It is suggested that the registrar enter notes from the ward round into the clinical record. This prevents misinterpretation of the plan formulated by the team.
The following facts, at least, should always be obtained from the consultant concerned and recorded in the notes: ◦ Whether he/she agrees or disagrees with the physical signs as set out in the chart
◦ His/her opinion concerning all relevant investigations ◦ His/her provisional diagnosis ◦ Planned investigational procedures ◦ Treatment proposed ◦ The FINAL DIAGNOSIS, future treatment and follow up arrangements. Attempt to take action about these immediately after the round.
Do not underestimate ward rounds as an opportunity to learn, and to impress. 5. ORGANISATION OF DISCHARGES Discharge planning begins from the time the patient is admitted and is a multidisciplinary approach on most wards. Always refer early to allied health staff (eg Occupational Therapist – home environment and equipment organised for discharge; Physio re mobility and if safe for discharge etc) so that discharge is not unnecessarily delayed. Assess fitness for discharge and confirm with registrar. The registrar, in turn, should ensure that the consultant responsible for the care of the patient is similarly advised. Patients should be discharged as early in the day as possible, in order to maximise the use of the available accommodation and prevent patients waiting for long periods to be admitted. If discharge is delayed for whatever reason, the patient may be able to wait elsewhere rather than continue to occupy a bed. Discuss this with the nurse in charge. Notify nursing staff of discharge plan & document clearly in notes. It is unreasonable for hospital beds to be occupied by patients from country centres who are well enough to travel home by public transport but are awaiting an ambulance from that centre. This can often take 2‐3 days. Use taxi vouchers (within reason) or other means for discharging patients in expeditious fashion.
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Organise discharge medications preferably day before. Prepare discharge letter and aim to give a copy to patient or carer before they leave the ward. Organise Ambulance Form day before discharge (but not on a Friday) and any certificates (eg Workers Compensation or Sickness Benefits). Liaise with GP particularly if patient’s condition unstable. If, for any reason, discharge has been delayed ensure discharge medications and other detail in summary remain appropriate. Arrange appropriate follow up and further tests. . If pathology testing is required on day of discharge, the request form should clearly state “PATIENT for DISCHARGE” so that specimens can be collected as priority. Arrange Outpatient appointment after discussion with registrar. *NB Each patient should have an Estimated Discharge Date (EDD) that is reviewed daily and communicated to both staff and the patient. Therefore, discharges and medications should be organised the day before discharge. 6. ORGANISATION OF TRANSFERS Ensure you are familiar with Hospital procedures BEFORE committing to or making arrangements for transfer of patients to or from other facilities, or for urgent consultations with external Specialists. Ensure all relevant details, including medications prescribed, results of investigations, are provided and detailed information documented in the medical record. 7. COMMUNICATING WITH RELATIVES If you don’t know the answer, say that you don’t know and advise you will find out if possible. Doctors are to make themselves regularly available for relative interviews. Every effort should be made to assist both patients and relatives during the patient’s stay in hospital. It is always advisable to be conservative in discussing patient status with family. Have regard to the wishes of the patient and/or legal health attorney in provision of details of diagnosis, treatment plans etc. Familiarise yourself with provisions in legislation in event of diagnosis of notifiable disease. 8. DETERIORATION OF PATIENT’S CONDITION Where a patient is diagnosed as being dangerously ill, the RMO or registrar should notify the relatives of this status as soon as possible and meet with them to discuss prognosis. Include senior nursing staff in your communications. A major deterioration in a patient’s condition should always be communicated to the registrar immediately and the consultant notified. 9. ORGANISATION OF CONSULTATIONS It is generally the RMO’s responsibility to organise any consultations which have been requested. Different protocols are followed according to whom the consultation is directed. Unless otherwise advised, requests for consultations from any other specialists should be handed to the registrar allocated to the Specialist. Ensure consulting registrar is given accurate history of patient’s presentation, results of investigations, response to treatment to date, what is being requested and why.
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10. PRIVATE (INTERMEDIATE) PATIENTS The care of Intermediate or Private Patients is the responsibility of the Consultant in charge of the case. The consultant or nursing staff will advise you if the consultant wishes you to see his/her patients. RMOs are required to provide the same calibre of care as given to public patients. In an emergency, the RMO should provide the best care possible to the patient and continue to manage the case until the consultant concerned is able to reach the Hospital, or the care is taken over by another Consultant (eg Intensivist). RMOs will not accept nor should they ask for any payment of any kind for treatment provided to a private patient. Failure to adhere to this requirement will render the officer personally liable for any damages in the event of any negligence or other claims and may result in disciplinary action. 11. PATIENTS FROM VARIOUS CULTURAL BACKGROUNDS Plan ahead for patients who may require language assistance; interpreters from external or in‐house sources should be booked in advance. Avoid using patient's relatives and friends as interpreters because they might have limited English skills and medical knowledge, and little understanding of confidentiality requirements. Be aware of resources such as Indigenous Liaison Officers that exist for Aboriginal and Torres Strait Islander staff and patients. 12. SUGGESTED DAILY ORGANISATION Organise general day in roughly this order: 1. Print out a list of your patients for the day. 2. Ensure request forms, etc. are done early (preferably the night before). 3. Ask the names of patients who are sick → see these people first (if possible, with
the registrar). 4. See the overnight admissions next and ensure investigations, etc. are organised. 5. Ensure you have not forgotten your ‘outliers’. 6. See the rest of your patients. 7. Routine admissions. 8. Check results from morning (and previous) investigations ordered. 9. Plan and organise discharges (medications, letters, ambulance bookings, etc.) the
day before preferably. (Know when Pharmacy closes). 10. If you have an early ward round, see the sick patients and check results of relevant
investigations prior to the round. 11. Before you leave for the day make sure that medication charts are updated to
avoid ward call residents from being asked to rewrite expired medication entries or enter doses for warfarin and insulin orders (which makes them very grumpy). This also applies to any routine pathology that needs to be written up for the next day.
12. Before leaving the hospital make contact with the ward call resident to handover details of patients you consider will need review within the next few hours.
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13. PROFESSIONAL DEVELOPMENT
Look for, and be prepared to reflect on, constructive feedback on your performance given to you from the consultant and registrar.
Demonstrate that you are a value‐adding member of the team by being enthusiastic and diligent in your work, taking initiative and making the most of all learning opportunities.
Contribute to improving safety and quality of care by offering feasible suggestions on how work practices and systems of care could be enhanced.
Lower the risk of harm being done to patients by regularly checking the actions of both yourself and those of your colleagues and being prepared to openly admit when error has occurred so that we may all learn from it.
Be prepared to assist your intern colleagues in times of need ie if their workload significantly exceeds yours, offer to lend a hand.
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Pathology Formed in 1997, Pathology Queensland consists of 33 laboratories based at public hospitals throughout the state. Pathology Queensland is a division of Clinical and Statewide Services (CaSS), and has approximately 1500 staff comprising consultant pathologists, scientists, technicians, operational and administrative staff. Pathology Resource Page The Pathology Queensland icon (maroon and white helix) is available on many PCs across the State. Alternately access http://qheps.health.qld.gov.au/pathology/home.htm Resources available via this link:
Pathology test list, which includes o Available tests and test search function o Collection requirements and tube types / colours o Transport requirements o Turnaround times o Laboratory contacts
Patient collection sheets
Request forms for public and Medicare‐eligible, and rural and remote patients
Public pathology price schedule
Information about our laboratories
Research and clinical trials information
I‐STAT online testing module,
Link to Clinical and State‐wide Services (CaSS) pages, and
Additional links to AUSLAB, AUSCARE and GP Connect resource pages
Blood Tube Recognition Chart See page 3. Specimen Collection Requirements Each sample to be tested must carry adequate identification of the person from whom it was collected. All specimens and request forms must have minimum two points of identification; ie either Full Name (surname and given name) and UR Number (two points)
or Full Name (surname and given name) and Date of Birth (two points) In addition, transfusion samples must have the signature or identifiable initials of the collecting officer on the sample and the date/time of collection. If the sample does not have the date and time of collection, but is signed and all other details are correct and there is a date and time on the request form, the transfusion sample will be accepted for testing. Where prior approval has been negotiated, HBCIS or similar labels are acceptable for specimen identification provided that the label is signed by the collecting officer.
Depending on the type of specimen, the following information may also be required for correct identification of the specimen: Ward/Hospital/Clinic Specimen Type (Anatomical Pathology & Microbiology Specimens)
Specimen Site of Origin (where appropriate) Specimens that are not labelled with full name and DOB, or full name and UR Number of the patient are considered inadequately labelled. The laboratory will issue a NO TEST notification via the AUSLAB laboratory information system, advising the clinician that testing was not performed. Request Form Requirements All specimens are to be accompanied by a request form signed by the collecting officer in the ‘all collectors must complete’ section and/or the person who supervised the collection in the case of patient collected specimens. For unsupervised patient collections (eg 24 hour urine collections), the staff member accepting the specimen is responsible for checking the details with the patient and signing the collectors section. The request form is a legal document that must be completed to confirm that the collecting officer has identified the patient and that the specimen is from the patient in question. Request forms must include:
Full patient details (as per specimen labelling requirements)
Ward / patient location
Details of requesting clinician, including signature and provider number (if you have one)
Tests required – full test names are preferable
Collector details
Collection details, ie time and date of collection
Relevant clinical notes Incorrectly or inadequately completed request forms may be rejected by the laboratory. Access to Pathology Results
The link to AUSLAB is present on all PCs. Pathology results will be available via AUSLAB once analysed. Clinicians require access to view results.
Auslab.lnk
Link to AUSLAB information and access forms: http://qheps.health.qld.gov.au/liss/auslab/auslab_forms.htm
AUSCARE, the web browser results review application for AUSLAB, is available at selected sites. Contact Laboratory Information Systems and Solutions (LISS) on 07 3000 9333, or visit http://qheps.health.qld.gov.au/liss/auscare/home.htm for more
information about AUSCARE.
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Prescription Writing Doctors may only prescribe drugs available on the Queensland Hospitals’ List of Approved Medicines (LAM), an electronic copy of which is available on QHEPS http://www.health.qld.gov.au/qhcss/mapsu/sdl.asp. When an individual patient requires the use of a drug not on the standard List of Approved Medicines advice must be sought from the local Director of Medical Services prior to prescribing. All QH Hospitals either have introduced, or are in the process of implementing, the Pharmaceutical Benefit Scheme (PBS). Patients can now receive up to one month's supply of medicines from the hospital on discharge. All legal aspects of drug management are governed by the Health (Drugs & Poisons) Regulations 1996. Inpatient Medication ordering ‐ basic requirements: See QH medication chart guidelines http://qis.health.qld.gov.au/DocumentManagement/Default.aspx?DocumentID=26669 The prescriber must ensure that all of the following occur:
Doctor’s own handwriting. (Pharmacists may also write out the drug order and obtain doctor’s authorisation)
The first prescriber must print the patient's name under the label to verify that both the ID label and the medication orders relate to the correct patient
Instructions must be legible.
Use of approved abbreviations only. See: http://qheps.health.qld.gov.au/medicines/documents/general_policies/abbreviations.pdf
Date of prescription clearly indicated.
Use of black, non‐water soluble ink is preferred; Eg, fountain pen is not to be used.
Use generic drug names with local exceptions allowed.
Adverse Drug Reaction section MUST be completed by the doctor as nursing staff will not administer any of the prescribed medications until this is done.
Administration times must be completed by the prescribing doctor.
To alter a prescription, cancel it and rewrite it.
All medications the patient is on prior to admission to hospital are recorded on the medication action plan (MAP) or, if this is not available on the front of the medication chart for reference purposes. (Red section at bottom of page). This does not constitute an order for these medications.
Discharge and outpatient prescriptions containing controlled drugs must provide:
The prescriber’s name, professional qualifications and address.
The date it is written.
The name and address of the patient for whom it is prescribed.
The patient’s date of birth
A description of the controlled drug or the name of the preparation and the quantity or volume (in words and figures) of the drug or preparation.
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No more than one drug request (ie the prescription may have multiple strengths of morphine or oxycodone, but not morphine and oxycodone on the same prescription).
Specific directions about the use of the drug. Such as “as directed” is not acceptable.
The dose to be taken or administered. Rational Drug Prescribing ‐ Ten general principles: 1. Is the proposed medication necessary? What is the financial cost? What are the
benefits versus the risks involved and what are the alternatives? 2. Know the characteristics of absorption, distribution, metabolism and elimination
of the drug to be prescribed, given the conditions of the patient’s age and know or possible co morbidities.
3. Determine the correct drug dose, form and dosage interval, taking into consideration the presence of any relevant disease state and/or administration difficulties.
4. Consider any likely drug‐drug interactions. 5. Be aware of the common adverse drug reactions (ADRs) for the drug prescribed. If
relevant, determine the uncommon reactions as well. If the patient is admitted or has a suspected ADR whilst in hospital, these should be reported on the ADRAC blue form and sent to pharmacy.
6. Has the patient had a previous ADR to the drug concerned, or had any other related side effects? If so, record the details of the ADR on the front of the drug chart. If not, tick the box marked ‘Nil Known’.
7. Inform the patient about the treatment proposed. Specifically, warn about any common and dangerous adverse drug effects or drug interactions.
8. Medication charts must be written legibly in ink. Ensure others can fully understand what you have written, and ensure that the dose and timing of administration are entered on the prescription. Check the doses in such as MIMS if unsure.
9. All medications should be reviewed regularly to identify potential drug interactions and drugs which may be discontinued if no longer required. When ceasing drugs, put a clear line through the actual order and the administration section. Write ‘Cease’ and sign and date the form. Ideally, the reason for ceasing should be added.
10. On discharge from hospital, fully inform the patient about the medications prescribed. In particular, try to discuss the need for adherence and the consequences of non‐adherence, warn about any likely drug effects on driving or use of machinery, and specify duration of treatment. If the patient is on long term medication, they must be informed that they need to obtain further supplies once the hospital supply has run out. In most cases, their GP can write repeat prescriptions. Specifically, inform the clinician taking over the patient’s care about the patients discharge medications.
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Antibiotic Use To ensure that antibiotics are prescribed appropriately, always consider the following 11 principles before selecting a specific antibiotic: 1. Ensure antibiotic use is indicated on the basis of clinical findings (treat the patient,
not the test). 2. Appropriate microbiological specimens should be obtained before commencing
the antibiotic. Eg blood cultures, sputum culture, micro‐urine, etc 3. If available, check prior microbiology and susceptibility results so that the right
drug is chosen. 4. Where there is uncertainty regarding the choice of drug, check Therapeutic
Guidelines: Antibiotic, available on the Clinician’s Knowledge Network. 5. As much as possible, antibiotics should be given singularly but occasionally,
combinations are indicated. These would include: broad spectrum cover required in severe sepsis of unclear aetiology, especially the febrile neutropaenic patient; poly‐microbial infection, eg intra abdominal sepsis or pelvic abscess; and where there is a need to limit or prevent the emergence of resistant organisms, eg tuberculosis.
6. Ensure that the patient is not allergic to the chosen drug; take care about class specific allergy eg Penicillin allergy means that drugs such as flucloxacillin, timentin, augmentin and amoxycillin are contraindicated.
7. Consider special factors related to the patient, particularly pregnancy and lactation, renal insufficiency and hepatic insufficiency.
8. Choose the best route of administration. Intravenous administration should always be used initially in serious infections
9. Plan the duration of the course of antibiotics when initiating treatment and indicate this on the drug chart.
10. Ensure that initial therapy is modified once culture results become available. 11. Change from intravenous to oral antibiotic as soon as practicable. Surgical Antibiotic Prophylaxis The choice of surgical antibiotic prophylaxis should follow the Antibiotic Guidelines unless instructed by Infection Control. This is important because it is one of the HQCC Standards to audit the proportion of principal surgical procedures the patient received antibiotic prophylaxis in line with the principles of Therapeutic Guidelines Antibiotic Expert Group, Prophylaxis Surgical Antibiotic Guidelines 13th edition. Prophylaxis should be considered where there is significant risk of infection (eg colonic resection) or where post‐operative infection would have severe consequences (eg infection associated with a prosthetic implant). Antibiotic prophylaxis cannot be relied upon to overcome excessive soiling, damaged tissues, inadequate debridement, or poor surgical technique. It is not necessary to include antibiotics that are active against every potential pathogen, only antibiotics directed against the likely pathogen. Infection Control will take into account organisms causing infections within the institution and their patterns of susceptibility.
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Infection Control Effective infection prevention and control is central to providing high quality healthcare for patients and a safe working environment for those that work in healthcare settings. Standard Precautions
Use appropriate personal protective equipment to provide a barrier to contact with blood, body fluids, non‐intact skin or mucous membranes
Ensure you are fully immunised
Use aseptic technique to reduce patient/client exposure to microorganisms
Manage sharps, blood spills, linen, and waste to maintain a safe environment
Ensure regular routine environmental cleaning
Hand hygiene Immunisation of Healthcare Workers It is recommended that all healthcare workers know their vaccination status for the following communicable diseases:
measles, mumps, rubella
hepatitis B (mandatory for Queensland Health’s healthcare workers)
hepatitis A
varicella zoster virus (chickenpox)
influenza
pertussis For more information: http://www.health.qld.gov.au/chrisp/policy_framework/framework.asp).
Hand Hygiene Hand hygiene must be performed:
before touching a patient
before performing a procedure
after a procedure or body fluid exposure risk
after touching a patient, and
after touching a patient's surroundings. For additional information, please refer to the Queensland Health Protocol 1: Hand Hygiene (available http://www.health.qld.gov.au/qhpolicy/docs/ptl/qh-ptl-321-1-1.pdf). The method of hand hygiene is displayed below:
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Sharps Management Occupational exposures to blood borne pathogens from needle stick and other sharps injuries are a significant but preventable problem. Injuries from needles and other sharp devices carry the greatest risk of transmission of a blood borne virus (hepatitis B and C and HIV). Handling and disposal of sharps must be done with care at all times. Sharps should not be re‐sheathed or manipulated by hand, and must be disposed of immediately into an appropriate receptacle at the point of generation by the person responsible for its generation. For more information: http://www.health.qld.gov.au/chrisp/policy_framework/framework.asp Transmission‐based precautions Transmission‐based precautions are used for patients known or suspected to be infected or colonised with epidemiologically important or highly transmissible pathogens that can cause infection:
by airborne transmission (eg TB, measles virus, chickenpox virus);
by droplet transmission (eg mumps, rubella, pertussis, influenza);
by direct or indirect contact (eg colonisation with ESBL, VRE and MRSA), or with contaminated surfaces, environment or equipment; or by any combination of these routes.
Transmission‐based precautions are applied in addition to standard precautions. In acute‐care settings, this will involve a combination of the following:
appropriate use of personal protective equipment (PPE)
patient dedicated equipment
allocation of single rooms or cohorting of patients
appropriate air handling requirements
enhanced cleaning and disinfecting of the patient environment
Further Information For further information http://www.health.qld.gov.au/chrisp/default.asp or contact your local infection control unit/practitioner or staff health coordinator.
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Pre‐admission Clinics The purpose of the Clinic is to determine the patient’s fitness and arrange appropriate referrals to optimise the health status of the patient in preparation for surgery or procedures. WHAT IS INVOLVED WITH PRE‐ADMISSION? Patients are fully pre‐assessed by junior doctor, anaesthetist, nurse and allied health staff as necessary. Patients are fully prepared for their scheduled surgery at this visit. Medical admission, consent, any pre‐op screening tests and anaesthetic assessment are conducted at these clinics. Consent is obtained and updated as required. This should done in consultation with a registrar or consultant, especially if you are uncertain of what is actually involved in the procedure. Consent forms and patient information forms can be found on QHEPS: http://www.health.qld.gov.au/consent/ Consent remains valid for 12 months. Ensure appropriate pre‐ and post‐operative education is given.
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SECTION D ‐ WARD CALL Summary of Do’s & Don’ts For Ward Call Do’s
Call a more experienced doctor when in doubt. If you would seek advice about the problem during daylight hours, then always do the same at night.
Listen to senior nursing staff.
Perform an Arterial Blood Gas (ABG) on Chronic Obstructive Pulmonary Disease (COPD) patients on increased oxygen.
Check blood tests from the day.
Manually check the vital signs yourself if it is abnormal.
Think of delirium when called to see an agitated patient. DON’TS
Never do anything you feel uncertain about – ring someone and ask.
Don’t give Non‐ Steroidal Anti‐ Inflammatory Drugs (NSAID) to any patient unless you notify a registrar.
Don’t give high flow oxygen to Chronic Obstructive Pulmonary Disease (COPD) patients.
Don’t do a rectal examination in neutropenia patients.
Don’t anticoagulate until a registrar is notified.
Don’t prescribe antibiotics until a registrar is notified.
Don’t have more than 3 attempts at IV placement. Get help.
Don’t commence antihypertensive medication or anticoagulants for stroke patients after hours without approval of consultant on call.
In hypertensive patients, don’t start any new medications or IV fluids without contacting the consultant or registrar first.
Don’t insert intravenous cannulae anywhere other than the back of the hand on renal patients.
Don’t give maxolon/metoclopramide to patients with Parkinson’s Disease Ward Call 1. Your purpose is to alleviate pain, react appropriately to important changes in
clinical status, liaise with the on call registrars and keep the patient safe. Work within your capabilities.
2. Prioritise calls in order of urgency. Those patients requiring resuscitation (or who have evidence of haemodynamic compromise) take priority over IV re‐sites, etc. If you have a backlog of calls you may need to stream patients into:
Priority 1: Emergencies Priority 2: Alleviation of pain Priority 3: Clinical management calls ‐ including IV re‐sites, blood checks and medication sheet authorisations.
3. Don't change long‐term treatment unless absolutely necessary. If you consider it
necessary to change the treating team’s management, call the registrar first. 4. Don't get over‐involved (bogged down!) trying to sort out chronic problems.
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5. The registrars expect to be called for advice. They are dedicated to providing support to ward call and reviewing patients who have become acutely unwell. Please do not hesitate to contact them with your queries.
6. As with day work, discuss the patient with the registrar covering that unit prior to consulting another discipline.
7. Don't feel obliged to respond pharmacologically to every problem. It may be appropriate to do nothing apart from reassure patients and/or ward staff. Don't be pressured into taking action when no action is required.
8. Some problems require an initial assessment followed by regular review.
Unnecessary intervention may be avoided in this way. 9. Use the telephone to your advantage. Politely insist that you are given sufficient
clinical data to formulate a differential diagnosis and assess the urgency of a problem before you hang up. Always ask for a brief background history and always ask for the patient’s observations. Request initial investigations by phone before you hang up, eg Urgent CXR, ECG, have IV trolley nearby, etc.
10. Assess each problem fully yourself. Requests such as "The patient just needs Maxolon ordered because she's vomiting." may actually be due to an underlying acute abdomen.
11. Remember, above all "Do no harm". Can the problem wait until the day staff arrive?
12. Legibly sign and print name and pager number in all chart entries. This facilitates feedback (which IS good). Chart entry must include: date, time, ATSP (asked to see patient) by nurse, brief history, examination findings, assessment management plan (including follow up) Progress notes must also state:
when there is any change in condition or diagnosis
when there is any change in treatment and why
when phoned to see the patient
when consultant sees or is phoned regarding patient’s condition 13. All IV's are difficult at 0300 hrs – consider if the IV can wait until morning. If it is
essential and you are unsuccessful after a few attempts call the registrar. 14. Be prepared for common calls eg
Prescribing variable dose medication e.g. gentamicin, warfarin, heparin and insulin – carry a copy of the dose nomograms with you, or know where to find them on CKN
Taking blood – know which tubes to use (see page 3 of this handbook)
Nocturnal sedation – know contra‐indications to hypnotics
Analgesia – morphine, fentanyl, endone, codeine, paracetamol, tramadol
Chest Pain
Pulmonary Oedema
Low urine output 15. Keep a record of all your calls ‐
Log should include: time of call, extension number, ward, name of patient, name of nurse, reason for call.
Take a patient sticker or write down the UR number so you can check blood results or x‐rays later.
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Ringing the Registrar This can be daunting, especially if you’re not sure what is wrong with your patient, but being prepared will make this call much easier. This will help you communicate your concerns, and also maximise the learning opportunities of Ward Call. 1. Formulate a diagnosis, investigation and management plan prior to calling. 2. If you do not have a good idea of what is wrong with your patient, that is okay,
but ensure that you have an adequate history, examination and review of current investigations ie bloods and XRs.
3. Tell the registrar what your diagnosis is, ± justification, and outline your management plan.
4. Ask if you may institute Rx (fluids ± analgesia may already have been given). 5. Remember, if the patient looks very ill from the end of the bed and the nursing
staff confirm deterioration in clinical state, CALL A REGISTRAR EARLY (or consider a MET call) and indicate to them clearly if you need their assistance urgently ie I’m very worried about Mrs X who is tachycardic and hypotensive due to GIT bleeding. Can you come to the ward urgently and help me?
6. After talking to the registrar, ensure that you understand the reason for the acute management plan and what the follow‐up should be. Ask for clarification if you are uncertain, then document the plan in the chart
Clinical Handover
Clinical handover refers to the process whereby professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, is transferred to another person or professional group on a temporary or permanent basis. Handovers permeate the healthcare system and can occur at shift change, when clinicians take breaks, when patients are transferred inter‐and intra‐hospital, and during admission, referral or discharge.
Handover processes are highly variable and may be unreliable, causing clinical handover to be a high risk area for patient safety. Breakdown in the transfer of information or in communication at handover has been identified as one of the most important contributing factors in serious adverse events and is a major preventable cause of patient harm.
Recommendations for effective clinical handover are:
If possible roster shifts to overlap
Minimise potential interruptions
Make sure you have the required documentation available to you e.g. medical record, ward/unit checklist
Make sure you have the required resources e.g. computer access, radiology/PACS, pathology results, Viewer
Patient risks and allergies should be included
Prioritise deteriorating patients
Ensure you are aware of the overall bed status of the hospital
Ask questions and seek clarification if you are unsure of any information being handed over to you.
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Handover should be performed face to face whenever possible, in combination with a written or computer generated handover sheet/checklist. High quality effective handover occurs when outgoing and oncoming staff members share a common “mental map” Use of communication tools such as I‐SBAR may assist with handover and referrals. ISBAR is a recognised communication tool and is appropriate for clearly defined urgent situations such as phone calls to ward call but is not a substitute for quality effective clinical handover. Handling Simultaneous Critical Calls Notify the registrar on duty of any serious calls to the wards that that cannot be attended within 10 minutes. Encourage nursing staff to activate MET calls where appropriate. In the event that the registrar is for some reason un‐contactable and the matter is urgent then a consultant on call should be advised and the matter handled as directed. Phone Orders Requests for Medication Always fully assess the problem yourself before prescribing anything. Think about what you are prescribing:
Is this medication necessary?
Do I have enough information to exclude … ? Take care when re‐prescribing:
What current and prn medications have been prescribed – have these medications been administered? Time last administered.
Is this medication still necessary? Is it the most appropriate medication?
Has the problem changed?
If no other option is available and you decide to give a verbal order:
use a once only dose
follow the procedure detailed in the section on verbal orders (below)
Remember, YOU are responsible, so don’t prescribe anything that you feel uncertain or uncomfortable about, and sign off any phone orders by the end of your shift ‐ only YOU can verify that what was given was what you intended.
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Verbal Orders Medication errors are a major source of potential patient harm and the use of verbal or phone orders is a particularly error prone practice. Verbal orders are more likely to result in inappropriate medication orders than written orders and as such, their use should be reserved for emergent situations. Whilst verbal orders may seem faster and more convenient, especially on a busy ward call shift, patient safety should take priority. You may feel pressured (either by time or nursing staff) to give verbal medication orders, however you should not prescribe anything without fully assessing the problem yourself (ideally in person) as this places you and your patients at risk.
Avoid verbal medication orders wherever possible.
Never use verbal orders where there is high potential for error (eg chemotherapy drugs) and avoid in high risk drugs: opioids, anticoagulants, potassium, or drugs which have complicated or ‘sound alike’ names.
Even ‘simple’ orders such as fluids or temazepam may cause patient harm.
Direct clinical assessment and review of contraindications remains the best method for safe prescribing.
Verbal Orders ‐ Safe Prescribing Due to the associated risks, verbal medication orders should be carefully considered and ideally reserved for emergent situations. If a verbal order is unavoidable, you should use the following process to reduce the risk of error and ensure patient safety: 1. Confirm patient identity 2. Spell the name of the medication 3. Consider using the trade as well as the generic name if potential for confusion 4. Avoid using abbreviations or short forms of drug names to avoid confusion 5. Clarify dose with spoken numbers (eg 15 milligrams: one, five milligrams) 6. Provide correct dosage units and specify route 7. Convey the indication for the medication 8. Ensure the order is clear and understandable to the recipient 9. Obtain a read back from a second nurse 10. Review the patient and sign off phone orders as soon as possible (within 24 hours)
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ISBAR Communication Tool ISBAR is a communication tool used for clear and concise communication with other health professionals. Examples include: Nurse to doctor re patient condition/deterioration
Ward nurse to pharmacy re D/C medications Medical to allied health referral Hospital to community referral Doctor to doctor handovers or referrals, including in emergencies
I‐ Introduction Identify who you are, and where you are from
S ‐ Situation Describe the situation B ‐ Background Give relevant background information A ‐ Assessment Provide an assessment R – Recommendation Suggests or requests actions Example:
I
Introduction‐ Identify who you are and where you are from “My name is John Citizens and I am the night medical ward call resident. I’m calling from Ward 1A”
S
Situation –Describe the situation “I am calling to get some advice about/I am calling because I need help urgently with … ( patient name and location.)
The patient's condition is… (stable/unstable )
The issue / problem I am calling about is ...”
B
Background –Give relevant background info “I have just assessed the patient :
Vital signs are: Blood pressure, Pulse, Respiration rate. SpO2 %, temperature I am concerned about the: (abnormal findings eg the patient's chest/abdomen/neurological examination ) I have requested these tests (CXR, ABG, ECG, FBC, or E/LFT’s or others) and the results are…”
A Assessment “I think the problem is… (e.g. I think the patient has severe acute pulmonary oedema)”
R
Recommendation Suggest or request:
“Can you please give me advice about how to manage this?
Can you please come to see the patient?”
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COMMON WARD CALLS This section of the handbook provides a brief overview of how to approach ward calls. Many of the problems can be approached using a 3‐step process: 1. Phone calls – pertinent questions to assess the urgency of a situation, and
treatment orders to be given to nurses and other staff on the ward prior to your arrival;
2. Thoughts in transit – the differential diagnosis and their important management points that you need to be thinking about as you make your way to the bedside from wherever you are when you first receive the call;
3. Bedside management – will include a quick look to place the patient into one of three categories: well, sick or critical; vital signs; selective history and physical examination; and subsequent detailed management.
Detailed information on how to manage specific problems is out of the scope of this handbook. For this information, recommended resources include: (CKN eBOOKS “On Call”, Marshall & Ruedy, Cadogan 1st ed) https://www‐mdconsult‐com.cknservices.dotsec.com/books/page.do?eid=4‐u1.0‐B978‐0‐7295‐3803‐9..X5001‐5&isbn=978‐0‐7295‐3803‐9&uniqId=287598495‐2#4‐u1.0‐B978‐0‐7295‐3803‐9..X5001‐5‐‐TOP UpToDate – database of common clinical conditions (CKN direct link on left‐hand side) http://www.uptodate.com/contents/search
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ANTICOAGULATION Guidelines for Anticoagulation using Warfarin Refer to WARFARIN GUIDELINES (usually located at the foot of patient bed) which have been developed by Queensland Health Safe Medication Practice Unit. Heparin Infusion Rates, Monitoring and Ordering Refer to the back of the HEPARIN INTRAVENOUS INFUSION ORDER & ADMINISTRATION FORM which has guidelines that have been developed by Queensland Health Safe Medication Practice Unit. CARDIAC ARREST Follow standard BLS/ALS guidelines Cardiac Arrest Pagers Ensure you are aware of your local Cardiac Arrest alerts procedures. It is important to know the composition of the Cardiac Arrest Team and what each person’s role is. You need to be absolutely sure you know how to activate an alert if you think a person is having a cardiac arrest. Priorities: 1. Activate the Cardiac Arrest Team 2. Control the situation 3. Access to Patient ‐ eg move bed 4. Connect O2 5. Maintain airway/check airway. 6. Resuscitate 7. Early defibrillation 8. Call for chart 9. Management from nursing staff "What happened?"
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CHEST PAIN There is a Queensland Health endorsed Chest Pain Pathway which can be substituted for clinical notes in the patient’s record. It allows doctors to risk stratify patients with chest pain and has been shown to minimise potential poor outcomes in patients with onset of chest pain. For more information go to the Clinical Practice Improvement Centre webpage: www.health.qld.gov/cpic DRIPS & PERIPHERAL IV CANNULATION The insertion of I.V Cannulae is an essential skill for doctors. Ensuring you are comfortable doing this procedure in non‐urgent situations will assist you when you are cannulating in an emergency. Many hospitals provide up‐skilling for medicalstaff who have not recently practised Cannulation – ask your medical education staff how to access these. Don’t Forget: ALL peripheral IVs must be changed at 72 hours unless there are extenuating circumstances. These MUST be documented in the chart. ENDOCRINOLOGY & METABOLISM HYPERGLYCAEMIA Refer to INSULIN INFUSION ORDER and BLOOD GLUSOSE RECORD – ADULT form. They are generally located at the foot of patient bed. DIABETIC KETOACIDOSIS (DKA) DKA occurs predominantly in patients with type 1 diabetes mellitus and is a medical emergency with a 3‐5% mortality risk usually from electrolyte disorders or cerebral oedema. Specialist medical advice should be sought as soon as possible. HYPOGLYCAEMIA Hypoglycaemia refers to a low plasma glucose level in conjunction with symptoms/signs of sympathetic nervous system activation or CNS dysfunction. Refer to back of INSULIN SUBCUTANEOUS ORDER and BLOOD GLUSOSE RECORD – ADULT form. They are generally located at the foot of patient bed.
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FALLS – WARD calls Resources available at: http://www.health.qld.gov.au/stayonyourfeet/resources.asp
Phone Call Questions/requests
Patient details and circumstances of fall ‐ both history and mechanics (SBAR). Establish if there are urgent concerns eg head injury or suspected fracture.
Vital signs (including GCS and BSL)
Review urgently if change in LOC, fracture or a coagulation disorder. If suspected head injury or unwitnessed fall, ask nursing staff to undertake
quarter hourly Neuro obs; Hourly HR, BP, Resp. rate, oxygen saturations,; ½ hourly for 2 hours; Hourly for 5 hours; 4 hourly for 8 hours.
Thoughts in Transit
What are the likely injuries (exclude fracture or head injury)?
If known coagulopathy, age>65, suspected head injury, on anticoagulants/anti‐platelets or fall from height >1m then order INR/APTT and CT head
What is the mechanism e.g. trip vs syncope?
Environmental factors e.g. most falls occur in hospital occur around the bedside or bathroom?
Bedside
Update from nursing staff including vital signs and GCS.
ABCs, check for injuries and categorise response.
If serious injury, deteriorating vital signs or new onset neurological signs, call registrar for help and commence stabilisation/investigation.
If not seriously injured then confirm history and perform examination. What preceded the fall/ do they remember it/associated symptoms eg incontinence, pre‐syncope/collateral from witnesses. Review hydration status/ medication that may be contributing/ mobility status/ postural blood pressure/Bone health/current falls assessment and care plan
Look at the fall in the context of the whole patient eg how have co‐morbidities contributed? eg delirium significantly increases falls risk and is under‐diagnosed.
Management
Establish reason for fall and work out what is modifiable
Arrange any immediate investigations required
If no head injury do above obs hourly for 4 hours, 2 hourly for 6 hours and 4 hourly for 8 hours
Pain relief if needed/ ice to affected area
Consider ongoing safety of patient eg increased observation for confused/ toileting plans
Ensure good documentation in patient record and communicate ongoing falls risk to treating multidisciplinary team so they can review and take action to decrease future falls risk and injury prevention.
Liaise with nursing staff to ensure that family will be notified and incident report (PRIME) will be completed.
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MENTAL HEALTH BASICS Mental Health Given the high prevalence of psychiatric disorders seen in the Emergency Department, medical, surgical, obstetric wards and in general practice, this overview may be useful irrespective of the nature of your current term. Risk Screen When conducting an interview, equally ensure the safety of the patient, yourself and others. If concerned never leave the patient unattended. Ensure your own safety by having an awareness of room entry and exit points, placement of duress alarms and process for calling additional staff to attend. Always consider risks every time you assess a patient with a mental health or drug and alcohol presentation, including suicide and self harm, aggression, vulnerability, absconding and dependent children/others. From your screening, patients with identified risk factors require further assessment via Mental Health Services (MHS). Depending on the care setting you are working in, further assessment by Mental Health Services may be arranged through a referral to Consultation Liaison Psychiatry or seeking consultation from an Acute Care Team. Mental Health Act 2000 (the Act) The purpose of the Act is to provide for the involuntary assessment and treatment, and the protection, of persons (whether adults or minors) who have mental illness while at the same time:
safeguarding their rights and freedoms; and
balancing their rights and freedoms with the rights and freedoms of other persons.
Two key requirements apply to persons who have responsibility for exercising powers and performing functions under the Act. These are:
any power exercised under the Act that affects the liberty and rights of the person should be exercised only if there is no less restrictive way to protect the person’s health and safety or to protect others; and
any adverse effect on the person’s liberty and rights is to be kept to the minimum necessary in the circumstances.
What you can do: The Act sets out processes for a person to be assessed for the purpose of determining whether involuntary treatment is required. The involuntary assessment process relies on assessment documents (request for assessment and recommendation for assessment) being completed for the person. Any registered medical practitioner is able to complete a recommendation for assessment. The Act also provides examination processes (emergency examination order and justices examination order) that may need to precede involuntary assessment in certain circumstances. These processes enable the person to be examined for the purpose of determining whether assessment documents can be made. As a registered medical practitioner you may be required to assess an individual under an emergency examination order or less commonly under a justices examination order.
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You may be asked to review patients who have been secluded due to imminent risk of violence when no less restrictive alternative is appropriate. Seclusion is defined as the confinement of the patient at any time of the day or night alone in a room or area from which free exit is prevented. Orders can only be made for a maximum of three hours. You must ensure the criterion of imminence of likely physical harm is satisfied. If you have any concerns, consult with the Psychiatry Registrar on call. Things you cannot do: Authorised Doctors and Authorised Psychiatrists have special roles under the Act. As Residents are not Authorised Doctors, there are certain forms and functions you are not permitted to complete. These include the making of involuntary treatment orders, authorising limited community treatment and developing treatment plans; ceasing or extending the involuntary assessment period; revoking involuntary treatment orders; completing transfer orders and issuing authority to return forms. Involuntary treatment of a physical illness is not authorised under the Act. It is not appropriate to use the Act for some instances where patients refuse assessment or treatment, even if deprived of capacity which usually includes delirium and uncomplicated dementia. For these purposes, the Guardianship and Administration Act 2000 provisions may be appropriate, utilising the Statutory Health Attorney of the patient to make decisions for them when capacity is impaired. Mental Health Medical Emergencies Medical emergencies can occur in mental health patients. Listed below are some that are more likely to be seen in MHS. Delerium Delirium is a medical emergency. It is one cause for agitated or disruptive patient behaviour, however it can also occur in a withdrawn patient as a hypoactive delirium. The manifestations of delirium include a reduced level of consciousness developing over a short period of time (hours to days), tending to fluctuate during the day, various cognitive deficits (disorientation, impaired memory or language functioning), and perceptual disturbance (hallucinations or illusions). This combined with the patient misinterpreting stimuli due to the cognitive impairment frequently leads to misdiagnosis of a psychotic illness. Undertake a thorough physical assessment including appropriate investigations to identify pathological aetiology and treat same. Neuroleptic Malignant Syndrome: This is a rare but life‐threatening adverse effect of antipsychotic medications. Patients are most at risk following commencement or dose increase of an antipsychotic medication, especially high potency typical agents. Features include rigidity, tremor, mutism, decreased consciousness level (from confusion to coma), hyperthermia, sweating, dysphagia, incontinence, tachycardia, high or unstable BP and elevated CK & WBC. Serotonin Syndrome: This is an increasingly common and serious complication of serotonergic medications, often as an interaction between multiple such agents when co‐prescribed. However it can occur from a single medication alone. These include psychiatric medications (SSRIs and some other antidepressants, lithium, sodium valproate), antiemetics (ondansetron, granisetron, metoclopramide), analgesics (tramadol, fentanyl,
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pethidine, pentazocine), sumatriptan, sibutramine, antibiotics (linezolide, ritonavir), dextromethorphan, drugs of abuse (including LSD and ecstasy/MDMA), and herbal preparations (hypericum/St John’s Wort, tryptophan, ginseng). Features include clonus, hyperreflexia, tremor, rigidity, ataxia, hyperthermia, agitation and sweating. Clozapine: This is a powerful antipsychotic medication. It can cause various physical adverse effects including tachycardia and postural hypotension. It can cause serious adverse events which might necessitate its cessation in a patient, for example clozapine‐induced myocarditis, cardiomyopathy, and agranulocytosis. It is important to differentiate clozapine induced tachycardia from the more serious myocarditis. Useful Hyperlinks RANZCP Clinical Practice Guidelines Mental Health Act 2000 Guardinship and Administration Act 2000
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SECTION E – Medico‐legal and Patient Safety Issues
Withholding and Withdrawing Life‐Sustaining Measures
Queensland Health Standard • The effect of this policy is to replace all local policies regarding the withholding and withdrawing of life-sustaining measures from adult patients. • The accompanying Acute Resuscitation Plan (ARP) form replaces all ‘Not For Resuscitation’ orders in Queensland Health facilities. • This policy does not authorise euthanasia or physician-assisted suicide. This policy applies
to both adult patients with capacity and adult patients without capacity to make decisions about health matters.
The scope of the
policy excludes children.
Withholding and Withdrawing Life-Sustaining Measures Implementation Standard 1. Purpose This implementation standard identifies the minimum (and auditable) requirements that evidence the implementation of the Withholding and Withdrawing Life-Sustaining Measures policy. It also identifies the accountabilities and responsibilities of individual positions in relation to these requirements. 2. Scope Adult patients of all Queensland Health public hospitals, state-wide services, outpatient services and community health services. The scope of this policy excludes children, and does not authorise euthanasia or physician-assisted suicide. 3. Definition of Terms See Glossary of Terms in Withholding and Withdrawing Life-Sustaining Measures Policy. 4. Supporting Documents (Procedures, Guidelines, Protocols etc) Withholding and Withdrawing Life-Sustaining Measures Implementation Guidelines National Health & Medical Research Council (RH&MRC)
Guidelines Ethical Guidelines for the Care of People in Post-Coma
Unresponsiveness (Vegetative State) or a Minimally Responsive State
Organ and Tissue Donation After Death, for Transplantation – Guidelines for Ethical Practice for Health Professionals
(Forms and Templates) Acute Resuscitation Plan form Priority Care Plan (under development) Advance Health Directives
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5. Requirements All clinicians and health professionals are required to act in accordance with the ethical and professional standards of their profession. That the Acute Resuscitation Plan form is filed at the front of a patient’s chart. Individual facilities may decide on the most prominent place to file the form. 6. Review This standard is due for review on: February 2011. 7. History Date of new / revised policy: Amended to
February 2010 New Standard 8. Responsibilities
Position Responsibility(ies) Accountabilities/ Audit Criteria
The patient
Is responsible for talking to those closest to them about their wishes for end of life care. If the patient has an Advance Health Directive and/or an Enduring Power of Attorney, the onus is on them to make its location known to their substitute decision-maker/s and, ideally, to the health care team.
N/A
The substitute decision-maker
Must respect the patient’s wishes for end of life care. All substitute decision-makers have an ethical and legal responsibility to act in accordance with the Heath Care Principle (see policy glossary). Not only must they exercise their powers in accordance with the patient’s best interests, they also have a duty to seek out the wishes of the patient and advise the health care team of those wishes in the event the patient loses capacity. The substitute decision-maker will also be called upon when the patient enters the dying phase to provide consent for decisions about life-sustaining measures. Consent obtained from a substitute decision-maker is not required to be in writing but should be documented.
Can be subject to legal liability if they do not act in accordance with the Health Care Principle.
The medical officer responsible for the patient’s care
Must respect the patient’s wishes for end of life care. Medical officers are required to adhere to the standards of good medical practice in all decision-making about end of life planning and care. The most senior clinician involved in a patient’s care is responsible for initiating advance care planning, such as an Acute Resuscitation Plan, and ensuring any decisions about advanced care planning and care with the patient and/or their substitute decision-maker are kept current. The medical officer is also required to ensure that the communication channels between
Carries the medicolegal responsibility for that patient while under their care.
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themselves and patient, their substitute decision-maker and the health care team remain open. The medical officer is also responsible for ensuring that the choices of the patient are respected and that all decision-making reflects their best interests.
Medical officers
Are required to adhere to the standards of good medical practice for their profession. There is a responsibility to ensure any treatments are provided in ways that promote quality of life for the patient and are in their best interests. Medical professionals have a duty of care to discuss with the most senior medical officer involved when the active treatments become burdensome for the patient and those closest to them. Junior medical officers should not be excluded when end of life decisions are considered, although they should be supervised in any discussions about end of life decisions with patients and/or their families. Junior Registrars are not advised to authorise a patient’s Acute Resuscitation Plan form.
Nursing professionals
Are responsible for adhering to standards of good clinical practice for the nursing profession. As well as having a key clinical role in observing and monitoring patient status and function, nursing professionals are often more accessible than medical officers in discussions with dying patients and their families. This means they have a responsibility to ensure any discussions about end of life care are recorded on the patient’s medical record, or if they have one, an Acute Resuscitation Plan. Nursing professionals should also be involved in case-conferencing with patients and those closest to them to ensure good communication between all clinical areas. Junior nurses should be supervised in all end of life discussions.
Allied Health professionals
Have a responsibility to act in accordance with the ethical and professional standards of their profession.
Pastoral care and community workers
Should be aware of the Health Care Principle if they are providing advice to substitute decision-makers.
General Practitioners
May have a patient’s original Advance Health Directive and/or Enduring Power of Attorney, and therefore when the time comes for
Carries the Medicolegal responsibility
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(GP)
decisions about withholding or withdrawing treatment to be made may be required to forward this document.
for that patient while under their care.
Dr Jeannette Young Chief Health Officer Approval Date: 15 February 2010 Implementation Date: 19 April 2010 For further information see http://qheps.health.qld.gov.au/policy/docs/pol/qh-pol-005.pdf
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Informed Consent The Queensland Health Policy statement Informed Consent for Invasive Procedures is available at: http://www.health.qld.gov.au/consent/documents/14025.pdf or see Patient Safety and Quality Improvement Service website: qheps.health.qld.gov.au/patientsafety Policy Statement: The responsibility for ensuring a patient has the necessary information and advice lies with the medical practitioner who performs a procedure, operation or treatment. In the event that the treating Medical Practitioner asks another Medical Practitioner (delegate) to obtain consent on their behalf, the treating Medical Practitioner remains legally responsible for ensuring that the Medical Practitioner obtaining consent fully understands and discloses the elements of consent to the patient/ parent/ guardian (if a child)/ substitute decision‐maker. The Medical Practitioner (or delegate) obtains consent from the patient/ parent/ guardian/ substitute decision maker according to the protocols which guide an effective communication process, ie
The procedure outlined in this policy, including the use of procedure‐ specific consent forms.
Relevant legislation, including the Powers of Attorney Act 1998 and the Guardianship and Administration Act 2000.
Procedure: (a) Presume all adults have legal capacity to consent. If in the event that the patient does not have capacity, see the Guardianship and Administration Act 2000, Power of Attorney Act 1998. For further information on obtaining consent for patients with impaired capacity, please refer to the consent flow charts on the Office of the Chief Health Officer's site on QHEPS http://qheps.health.qld.gov.au/cho/resources/pdf/17229.pdf (b) The treating Medical Practitioner or delegate, seeking consent to Medical
Treatment of the patient/ parent/ guardian (if a child)/ substitute decision‐maker must be able to comprehensively discuss the issues in relation to medical treatment set out in paragraph (c) and (d) below.
(c) Ensure that, in so far as it is possible:
Consent is voluntarily given, in absence of the influence of therapeutic or other drugs or alcohol, family, religious, cultural and medical staff influences; The patient/ parent/ guardian (if a child)/ substitute decision‐maker has sufficient time to consider the information provided by the doctor.
(d) The patient/ parent/ guardian (if a child)/ substitute decision‐maker is advised in lay terms of: The diagnosis Recommended treatment; Material risks in percentage terms associated with:
− The recommended treatment. − Alternative treatment options. − The no treatment options.
in so far as a reasonable person would expect to be advised of significant risks;
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AND
Significant risks for the particular patient, AND
That no assurance can be provided that the treating Medical Practitioner will carry out the treatment option.
(e) A competent adult may refuse any and all medical treatment contrary to medical
recommendations even in circumstances where such refusal may result in the death of the patient.
(f) Generally, a parent makes the decision for their child. However, where the child
has sufficient maturity and understanding of the proposed procedure, then the child is legally able to make their own decision. In the event of a conflict between a parent and a child, the Family Court or the Supreme Court (depending upon the circumstances) have the general power to intervene in the interests of the child
Informed Consent Program The informed Consent Program has developed patient information sheets and consent forms for those invasive procedures to be highest risk. These are loaded on: http://www.health.qld.gov.au/consent/html/for_clinicians.asp
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Certifying (or Pronouncing) and Reporting Death Many hospitals provide the required paperwork and forms required to be completed in "Deceased Packages" usually available on the wards. Available statewide (see: http://qheps.health.qld.gov.au/patientsafety/htm/coro_mgt.htm) these packages are usually electronic and available as an icon on each desktop. Upon the death of a patient in hospital, the doctor who is called to pronounce death is to confirm that death has indeed occurred (using the recognised clinical criteria for death). Document your findings in the patient's chart. A typical chart entry may read as follows:
Called to pronounce Mr Smith deceased. Patient unresponsive to verbal or tactile stimuli. No heart sounds heard, no pulse felt. Not breathing, no air entry heard. Pupils fixed and dilated. Patient pronounced deceased at 1830 hours, December 10, 2009
The doctor certifying the death should check the patient identification bracelet is correct and is securely attached to the correct patient. Certificates For deaths not reportable to the coroner, where the cause of death is known, complete the appropriate documentation Life Extinct Certificate or Cause of Death Certificate. Under section 30 of the Births, Deaths and Marriages Act 2003, a doctor must issue a Cause of Death Certificate if they can form an opinion about the probable cause of death. The doctor must have either:
Attended the deceased when the person was alive; Examined the deceased person’s body; or Considered information about the deceased person’s medical history and the circumstances of the deceased person’s death. The Cause of Death Certificate must be completed as soon as practicable during the office day on which the treating doctor is so informed.
If you are uncertain about how to correctly document the cause of death, approach a senior doctor for assistance and your hospital medico‐legal officer. If a non‐coronial autopsy is to be done, the treating doctor must obtain the consent of the next of kin, complete an autopsy request form (including relevant clinical details) and contact the pathologist promptly. The chart, Cause of Death Certificate, autopsy request form and completed autopsy consent and authorisation form are to be delivered to the pathologist as soon as possible. If the death is reportable (see http://www.courts.qld.gov.au/courts/coroners‐court and http://www.legislation.qld.gov.au/LEGISLTN/CURRENT/C/CoronersA03.pdf) ask a senior doctor and your hospital medico‐legal officer for advice.
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Generally, deaths are reported to the coroner by police. In some cases, deaths can be reported directly to the coroner by the hospital or doctor who has been treating the deceased person. Example:
The medical practitioner seeks advice from the coroner about whether a death is/is not reportable, or
The death is reportable and the medical practitioner seeks the coroner’s authority to issue a cause of death certificate because cause of death is known and no autopsy or investigation appears necessary.
Notes: Staff must NOT recommend a specific funeral director to bereaved relatives. Rather, they should give the names of all the local firms and leave it up to the relatives to decide. Perinatal deaths (stillborn or less than 28 days old) require both a Cause of Death Certificate (Form 9) and a Perinatal Supplement (Form 9A) to be completed. Please treat the completion of Cause of Death Certificates as a matter of priority. Unnecessary delays add an additional burden to bereaved relatives. It is usually the duty of the RMO who was responsible for a patient immediately prior to that patient’s death (the "treating doctor") to attend to cause of death certification. Where any difficulty is encountered the onus is on the RMO nominally responsible at the time of a patient’s death to take active steps to minimise delay in issuing the Cause of Death Certificate, and if necessary, to contact the Executive Director of Medical Services for guidance.
What is a reportable death?
Refer to the Coroners Act 2003 (http://www.legislation.qld.gov.au/LEGISLTN/CURRENT/C/CoronersA03.pdf) Reportable deaths are defined as deaths where
the identity of the person is unknown the death was violent or unnatural the death happened in suspicious circumstances a ‘cause of death’ certificate has not been issued and is not likely to be issued the death was a health care related death the death occurred in care the death occurred in custody the death occurred as a result of police operations.
For further information see http://www.courts.qld.gov.au/1702.htm The Patient Safety and Quality Improvement Service website: http://qheps.health.qld.gov.au/patientsafety/htm/coro_mgt.htm provides a Coronial Management Resources with information on coronial guidelines, Life Extinct Flowchart , Preserving evidence when a "Reportable Death" occurs in a health care setting. .
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PRIME (Clinical Incident Management Information System)
A "clinical incident" is any event or circumstance which has actually, or could potentially, lead to unintended and/or unnecessary mental or physical harm to a patient of Queensland Health. Clinical incidents include adverse events (harm caused) and near misses (no harm caused).
The Clinical Incident Management Implementation Standard
(http://qheps.health.qld.gov.au/policy/docs/imp/qh‐imp‐012‐1.pdf) provides staff
with a comprehensive "how to” guide that not only outlines responsibilities for all
levels of staff in relation to clinical incidents, but also the necessary tools and
processes to enable this to be achieved. The Clinical Incident Implementation
Standard:
Defines what incident types are considered within the scope of the Standard and
how they should be managed;
Describes when and how a Root Cause Analysis (RCA) is conducted for a
reportable event;
Defines alleged Blameworthy Acts and includes guidance on when not to conduct
or cease a Root Cause Analysis;
Provides clear rationale and defined processes that enable Queensland Health to
learn from adverse events and near misses and take corrective actions to
improve safety for all patients. All doctors should be aware of PRIME and understand how and when to use it. Ensure you attend training (ask your Medical Education Unit for local information). For further information see the Patient Safety and Quality Improvement Service website.